ONLINE EXCLUSIVE Evaluating CAPDOTS Training for Children and Adolescents with APD By Jay R. Lucker, EdD, CCC-A/SLP, FAAA; Cydney Fox, AuD; and Bea Braun, AuD

uditory processing disorders (APD) in school-age children can lead to learning problems.1 Audiolo- gists may determine the presence or absence of APD in this population and make specific thera- Apeutic recommendations. However, many therapies for APD have not been peer-reviewed or examined with statistical analysis to determine efficacy. The present study evaluates a therapeutic option called CAPDOTS-Integrated (also referred to as CAPDOTS), an online training program that aims to im- prove dichotic listening problems. According to Jerger, “Dichotic listening (DL) tests are at the core of the diagnostic evaluation of auditory processing disorder... [Such tests] have been used for decades both as screening tools and as diagnostic tests in APD evaluation.”2

Thus, audiologists evaluating school-aged children for APD AdobeStock may find these children to have dichotic listening problems. Those diagnosed with dichotic listening problems are rec- subjects.2 The 27-year-old subject identified as diagnosed ommended to try a dichotic listening training program, such with “binaural integration deficit” only completed 80 percent as CAPDOTS-Integrated.1 Presently, CAPDOTS-Integrated of the CAPDOTS training. The 16-year-old subject is re- claims to treat binaural auditory integration problems known ported diagnosed with a binaural integration (dichotic listen- as dichotic listening difficulties. CAPDOTS is a treatment ing) auditory processing disorder. Results of mid-latency program requiring access to the internet and good quality electrophysiological measures revealed increased response headphones. It can be completed in the trainer’s office, at findings after these subjects completed CAPDOTS. Quali- school, or home.1 On their website, it states that CAPDOTS–­ tative data discusses the Na-Pa amplitude changes and per- Integrated “improves the ability to follow complex, multi- cent differences for each subject. Statistical analyses were step directions, listening attention especially in distracting not used so there is no indication whether these changes background noise, inferential listening and understanding of were significant. group instructions, auditory memory, academic perfor- The second conference presentation, also by Carol Lau, mance especially for reading comprehension and spelling.”1 used only three subjects, all identified as having auditory pro- However, one may ask what evidence supports these cessing problems based on scores from the SCAN and claims? ­Dichotic Digits Tests.4 Number values are the only results pro- vided. There were no statistical analyses discussed. A third reference is an article published in The Hearing EVALUATING THE SUPPORTING Journal on a study involving three adults identified with co- RESEARCH morbid peripheral hearing loss and CAPD.5 Each subject was The CAPDOTS website cites two conference handouts on used as a single case study presenting results of auditory pro- the changes after CAPDOTS training. Carol A. Lau dis- cessing tests pre- and post- CAPDOTS training. Findings cussed mid-latency, electrophysiological responses in two identified improvements after CAPDOTS training, but no sta- tistical analyses were provided. From left: Jay R. Lucker, EDD, CCC-A/ Another study published in 2013 used individual case SLP, FAAA, is a professor and the presentations including one of a second-grade boy with audi- director of the five-year accelerated tory processing problems, an older adult who suffered a head master’s degree program in the de- injury, a preteen with no history of educational or auditory pro- partment of communication sci- ences and disorders at Howard cessing concerns, two girls identified by qualitative observa- University in Washington, DC. He tions having problems following verbal interactions and also has a part-time private practice specializing in issues related to audi- directions, and an adult with a history of learning disabilities.6 tory processing disorders. Cydney Fox, AUD, is a member of the Craniofa- All subjects were evaluated using the SCAN test as well as cial Team at Orthopaedic Hospital and a full-time audiologist at Audiology Dichotic Digits. Data compared pre- and post- CAPDOTS Solutions LA. Bea Braun, AUD, is a clinical audiologist and a credentialed educational audiologist. She founded the Auditory Processing Center of training with improvements noted, but no statistical analyses Pasadena. were provided.

The Hearing Journal April 2021 ONLINE EXCLUSIVE

Table 1. Ranges, Means, and Standard Deviations Table 1. Continued... for each of the Measures of Auditory Processing Standard used in the Present Study (N = 46) Test Measure Range Mean Deviation Standard Test Measure Range Mean Deviation Left Ear First RE-pre 4-15 10.3 2.88

Competing Right ear-pre 80-100% 93.9% 6.58% RE-post 8-15 12.3 1.62 Sentences LE-pre 3-13 8.2 2.57 Right ear-post 88-100% 97.4% 4.44% LE-post 5-14 10.1 2.23 Left ear-pre 50-100% 78.6% 15.97% SCAN-3 Left ear-post 30-100% 80.4% 19.17% Auditory Figure- Dichotic Right ear-pre 50-95% 84.7% 13.61% Ground +8 RE-pre 17-20 18.6 1.1 Digits RE-post 16-20 18.7 1.4 Right ear-post 73-100% 92.9% 7.33% LE-pre 13-20 18.1 1.9 Left ear-pre 35-95% 74.0% 14.20% LE-post 16-20 18.8 1.1 Left ear-post 40-100% 82.4% 50.58% Duration Pre 40-73% 50.6% 18.44% SCAN-3 Patterns Time RE-pre 17-30 25.7 3.7 Post 17-84% 56.0% 20.09% Compressed Frequency Pre 10-100% 58.5% 24.59% Sentences RE-post 22-30 27.8 2.9 Patterns LE-pre 19-29 24.9 2.7 Post 50-100% 84.7% 16.27% LE-post 22-30 26.9 2.2 Low Pass Right ear-pre 32-90% 71.6% 17.36% Filtered Right ear-post 64-92% 82.9% 8.90% Left ear-pre 32-86% 66.4% 16.32% PURPOSE OF THE PRESENT STUDY Left ear-post 40-96% 79.4% 14.03% Studies have looked at changes in auditory processing after Phonemic Quantitative- 0-23 16.2 5.51 completing CAPDOTS training. However, none provides sta- Synthesis pre tistical analyses, and all use small samples. The present Quantitative- 16-24 20.6 2.98 looked at a large sample of children and adolescents diag- post nosed with APD. The researchers measured what changes Qualitative-pre 2-23 13.9 5.73 occur when statistical analyses are used. The research ques- Qualitative- 8-24 18.8 4.51 tions asked whether auditory processing test findings re- post vealed significant improvements after completing CAPDOTS SSW RNC-pre 0-10 2.6 2.61 training, and for what specific measures, as well as investigat- RNC-post 0-4 0.6 0.99 ing the degree of improvement following training. RC-pre 0-27 8.6 5.95 RC-post 0-15 3.1 3.42 STUDY METHODS LC-pre 5-34 14.3 6.93 Forty-six children and adolescents (26 males and 20 females) LC-post 2-22 8.3 5.09 participated in the study. Two of the authors (CF and BB), LNC-pre 0-19 3.9 4.18 both licensed clinical audiologists, evaluated participants LNC-post 0-7 1.2 1.39 identifying all having significant APD. Participants ranged SCAN-3 from 6 years to 18 years with a mean age of 10.0 years Competing RE-pre 6-35 12.3 8.67 (standard deviation of 2.70 years). Participants had normal Sentences hearing which would not influence their auditory processing RE-post 12-35 12.6 7.19 or treatment. LE-pre 4-34 8.2 8.14 Auditory Processing Tests: Auditory processing was as- 7 8 LE-post 10-22 9.2 6.03 sessed via the SCAN-3 C for children and A for adolescents 9 SCAN-3 Dichotic Digits (DDT), Frequency Patterns and Duration Pat- terns,10 Competing Sentences,11 Low Pass Filtered Speech,12 Competing Words- Directed Ear SSW Test,13 and the Phonemic Synthesis Test (PST),14 using Right Ear RE-pre 3-14 10.7 2.49 First the specific scores for each ear or individual measure on the tests. RE-post 7-14 11.5 2.03 CAPDOTS Training: CAPDOTS is a web-based therapy LE-pre 1-12 6.8 2.86 based on a Staggered Dichotic Listening Training (SDLT) LE-post 5-14 8.8 2.52 paradigm, using words, digits, and syllables. SDLT uses a ­difference in the timing presentation of targets in each ear

April 2021 The Hearing Journal ONLINE EXCLUSIVE

RESULTS & DISCUSSION Table 2. Results of Paired (Dependent) Samples A total of 24 measures were completed in the study. Table 1 t-tests on all Measures presents the results of the pre- and post- CAPDOTS meas- Test Measure t p ures, indicating large differences between the post- and pre- Competing Sentences Right ear 1.550056 0.1494 therapy findings. Table 2 shows the t-test statistical analyses results, which Left ear 0.547209 0.59516 reveal significant findings for 16 of the 24 measures. Only Dichotic Digits Right ear 5.887257 <0.00001* one dichotic measure (Right Ear for Competing Words-­ Left ear 2.531742 0.01743* Directed Ear Right Ear First) was not significant. The remain- Duration Patterns 1.234108 0.24288 ing 7 dichotic measures were significant. Thus, significant Frequency Patterns 5.803375 <0.00001* findings were found for 7 of the 8 dichotic measures of audi- tory processing. Low Pass Filtered Right ear 2.61608 0.02134* Surprisingly, CAPDOTS training not only significantly im- Left ear 3.585902 0.00332* proved dichotic listening but also made significant improve- Phonemic Synthesis Quantitative 5.809389 <0.00001* ments in other areas of auditory processing. Nine measures Qualitative 8.102465 <0.00001* were also found to have significant t-test results. Therefore, SSW RNC -5.946805 <0.00001* the present study indicates that CAPDOTS therapy can show significant improvements in dichotic listening as well as in RC -8.836471 <0.00001* other areas of auditory processing. LC -8.986836 <0.00001* To determine how much change was found after CAP- LNC -4.690867 0.00003* DOTS training, a post hoc analysis was conducted for the 16 SCAN-3 significant measures found. This analysis determined the ef- Competing Sentences RE 0.2470897 0.78585 fect size of change using Cohen’s d for dependent samples. Table 3 presents the results of these calculations. LE 0.79106 0.43699 Cohen’s d values range from no significant effect (less SCAN-3 than .20) to a small effect (from .20 to .49), a medium effect Competing Words-Directed Ear (from .50 to .79), a large effect (from .80 to 1.0), and very Right Ear First RE 1.603042 0.12051 large effect (greater than 1.0). These values are measures of the number of standard deviation change occurring. A review LE 2.845347 0.00941* of Table 3 indicates that only one measure revealed a small Left Ear First RE 5.013774 0.00003* improvement and three showed a medium improvement. LE 4.66104 0.00008* Large improvements were found for six measures and very SCAN-3 large improvements for six other measures. Thus, the majority Auditory Figure- of improvements were found to be large and very large. Ground +8 RE 0.722672 0.47749 LE 1.636319 0.12015 CONCLUSIONS SCAN-3 Results of the present study indicated significant improve- Time Compressed RE 3.231994 0.00559* ments in dichotic listening with 7 of the 8 measures showing Sentences LE 4.552721 0.00025* large and very large effect sizes. What was surprising was that 9 non-dichotic measures of auditory processing revealed * significant at p<0.05 significant changes after CAPDOTS therapy. Thus, the con- clusion drawn is that CAPDOTS therapy not only can make a significant improvement in dichotic listening but can also starting with a gap between stimuli presented to each ear change other auditory processing factors. Changes were with the gap decreasing until the two stimuli are presented found in auditory temporal processing (Frequency Patterns simultaneously. and Time Compressed Sentences for each ear), understand- Participant CAPDOTS therapy at home with monitoring by ing distorted speech (Filtered Speech), and auditory phono- the audiologist. Upon completion of CAPDOTS training, the logical processing (Phonemic Synthesis). Thus, professionals auditory processing evaluation was re-administered. Thus, recommending CAPDOTS training for children and adoles- pre- and post- training scores were available and were com- cents with auditory processing disorders should not only ex- pared allowing for statistical analyses of the data. pect improvement in dichotic listening and auditory integrative Data Analyses: A paired (also called dependent) samples processing but also in other areas identified above. t-test was calculated for each measure. Performance for the One important outcome from the present study relates to right ear was compared separately from performance for the what is stated on the CAPDOTS website1 that CAPDOTS left ear when appropriate. -test scores yielding probability training should lead to improvements in a variety of areas values less than 0.05 identified that the change was signifi- which include listening in noise, understanding verbal mes- cant. Significant t-test findings were then evaluated by sages in groups (which may relate to listening in noise), read- ­Cohen’s d. ing and spelling abilities. The findings from the present

The Hearing Journal April 2021 ONLINE EXCLUSIVE

people with these diagnoses, CAPDOTS therapy might be Table 3. Results of Cohen’s d Effect Size analysis beneficial in improving their auditory processing abilities. for measures that showed significant differences Further research may wish to look at subjects diagnosed on the paired sample t-tests. with ADHD or with ASD and compare these participants Test Measure Cohen’s d Effect Size with subjects not found to have neither of these psychologi- Dichotic Digits Right ear 0.931 Large cal issues. Left ear 0.462 Small Another limitation of the present study relates to the spe- cific auditory processing tests used. Other tests used by au- Frequency Patterns 1.117 Very Large diologists may need to be statistically evaluated to determine Low Pass Filtered Right ear 0.699 Medium if there are significant changes following CAPDOTS training. Left ear 0.918 Large Areas such as auditory (listening) attention were not evalu- Phonemic Synthesis Quantitative 1.094 Very Large ated. It would be interesting to see what changes might occur Qualitative 1.505 Very Large on a measure of auditory attention such as the Auditory Con- tinuous Performance Test (ACPT)15 following CAPDOTS SSW RNC 0.897 Large therapy. RC 1.332 Very Large One other limitation of the present study relates to age. LC 1.355 Very Large Participants were children from 6 to 12 years old as well as LNC 0.707 Medium adolescents from 13 to 18 years old. It is likely that children performed differently from adolescents. Thus, future research SCAN-3 may wish to compare findings for children versus adolescents Competing Words-Directed Ear to determine if differences may be found based on age. Right Ear First LE 0.593 Medium Whatever the limitations, the present investigation looked Left Ear First RE 0.948 Large carefully at a large group of children and adolescents who LE 0.881 Large completed CAPDOTS-Integrated training online. The findings indicated very significant changes in dichotic listening as well SCAN-3 as in other areas of auditory processing not specific to di- Time Compressed RE 0.808 Large chotic listening. The conclusion is that after CAPDOTS train- Sentences LE 1.440 Very Large ing, one should expect to see significant improvements in various aspects of auditory processing. evaluation indicated significant improvements in auditory phonological processing which would be related to reading REFERENCES decoding and spelling abilities. However, no improvements were evidenced for listening in noise. Results of the Auditory 1. Capdots. https://capdots.com/about-capdots/the-system 2. Jerger J. (2007). Editorial: Dichotic Listening in the Evaluation of APD. Figure-Ground measures used were not significant (p>0.05) Journal of the American Academy of Audiology, 18(1). for either the right or left ears. Although the CAPDOTS web- 3. Lau C (2016a). Auditory Mid-Latency Response (AMLR) Pre- and Post- site does not address auditory temporal processing skills Dichotic ListeningTraining Using CAPDOTS. https://capdots.com/ which are important, the results of the present study indicate wp-content/uploads/2017/10/DichoticListening_HandoutWeb.pdf significant improvements in this auditory process. Perhaps 4. Lau C (2016b). Long-Term Maintenance of Dichotic Listening Skills Follow- ing Training Using CAPDOTS. https://capdots.com/wp content/ this is due to the subject’s ability to more rapidly process uploads/2017/10/Dichotic­Listening_HandoutWeb.pdf (time compression) and be better able to understand the pro- 5. Lau C.A. (2016). Staggered dichotic listening training using CAPDOTS- sodic features of the verbal message (frequency pattern pro- Integrated in Hearing-Impaired Adults. Hearing Journal. https://journals. cessing). Additionally, integrative processing (dichotic lww.com/thehearingjournal/blog/onlinefirst/Lists/Posts/Post.aspx?ID=7 6. https://www.slideshare.net/capdots/capdots-case-studies listening) can contribute to other aspects of listening be- 7. Keith RW (2009b). SCAN-3 A: Tests for Auditory Processing Disorders in cause it involves processing the meaning of what is spoken Adolescents and Adults. New York, NY: Pearson Publishers. to the listener. 8. Keith RW (2009a). SCAN-3 C: Tests of Auditory Processing Disorders in Children. New York, NY: Pearson Publishers. 9. Musiek F. (1983). Assessment of central auditory dysfunction: The Dich- LIMITATIONS & FUTURE RESEARCH otic Digit Test revisited. Ear and Hearing, 4(2), 79–83. 10. Musiek FE (1994). Frequency (pitch) and duration pattern tests. Journal of As with any study, there can be limitations leading to recom- the American Academy of Audiology, 5(4), 265-268. mendations for further research. One limitation could be 11. Auditec, Inc. (2015a). Competing Sentences. https://auditec.com/2015/ considered the number of participants used. This study in- 09/22/competing-sentences/ 12. Auditec, Inc. (2015b) Low Pass Filtered Speech. https://auditec. cluded 46 participants all identified with auditory processing com/2015/09/25/low-pass-filter/ disorders. However, the specifics of each participant’s audi- 13. Katz, J. (1968). The SSW test: An interim report. Journal of Speech and tory processing issues were not identified. Some partici- Hearing Disorders, 33, 132-146. pants might have had additional issues such as attention 14. Katz, J., & Harmon, C. (1981). Phonemic Synthesis: Diagnostic and Train- disorders (ADHD) or autism spectrum disorder (ASD) that ing Program. In R. Keith (Ed.), Central Auditory and Language Disorders in Children. Houston: CollegeHill Press. were not identified. However, if participants had ADHD or 15. Keith RW (1994). Auditory Continuous Performance Test (ACPT). Lon- ASD, findings from the present study suggest that even for don: Pearson.

April 2021 The Hearing Journal